Hayfever Questionnaire

Hayfever Treatment

DO NOT USE THIS FORM IF YOU ARE PREGNANT OR BREASTFEEDING. DO NOT USE THIS FORM FOR CHILDREN AGED 5 YEARS AND UNDER.

If you are pregnant or breastfeeding or for children 5 years old and under please call the surgery and arrange a GP appointment or request a call back with a GP

Full Name:*

Date of Birth:*

Have you been diagnosed with hayfever (seasonal allergic rhinitis) by a healthcare professional previously?

Yes

No

What symptoms do you suffer with?*

Have you tried all available over the counter treatments without success (e.g the antihistamines 'cetirizine', 'loratadine' and 'Piriton' and the nasal steroid spray 'Beconase')?*

YES

NO

If you have not tried these, please do not continue with this form but instead go to a pharmacy where a pharmacist will be able to assist you.

What prescription treatments have been effective for you in the past?*

Do you know what months of the year you normally experience symptoms? (please type the months or 'No', if you do not know in the box below)*

Did you know that starting a regular nasal steroid spray 1-2 weeks before the anticipated start of your symptoms each year often greatly reduces the severity of the symptoms you experience through the hayfever season? (Why not set a reminder on your phone?)

Do you have any kidney, liver or heart problems?*

Yes

No

Do you have glaucoma?*

Yes

No

Have you had any recent untreated/unresolved nasal infections, been told you have nasal polyps, or had recent nasal surgery?*

Yes

No

If you have answered yes to the above question please provide brief details

We know hayfever comes on quickly, so aim to get back to you within 1 WORKING day.